Medical Providers Credentialing Client Discovery Form

Credentialing Client Discovery Form

(Medical Providers Credentialing)

Purpose:

This form focuses on gathering information on existing billing operations, transition readiness, A/R, denials, reporting, and ongoing revenue-cycle support.

EHR/PM software, clearinghouse, payer portal access, and active payer enrollments are expected to be already established.

Instructions:

• Complete every applicable field. Select only services currently provided or planned.

• Upload supporting documents through the secure upload fields. Do not email protected or sensitive documents.

• Items marked “if applicable” may not apply to every provider or practice. Upload documentation through the secure portal only.

Application Progress1 / 14

Service: Medical Providers

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Legal Business Name (must match IRS) *

DBA / Facility Name

Tax Designation *

Organization Type *

Solo Practice Group Practice Multi-Specialty Group Specialty Clinic Hospital-Owned Clinic Academic / Teaching FQHC/RHC Urgent Care Telehealth-Only Mobile Practice Other

Primary Specialties *

Family Medicine Internal Medicine Pediatrics Geriatrics Preventive Medicine Women's Health Behavioral Health Other

Practice Type *

Office-Based Hospital-Based Hybrid Procedure-Based Consultative Specialty Telehealth-Only Mobile / Home-Based Other

Group Taxonomy *

Opening Date

States of Operation *

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Guam U.S. Virgin Islands Northern Mariana Islands

Number of Locations

Website URL

Primary EHR System

Patient Portal Available?

Yes No

Primary Contact Name *

Title *

Phone *

Email *

Secondary Contact Name

Secondary Contact Title

Secondary Contact Phone

Secondary Contact Email

Primary Service Location Address *

Billing Address Same as Physical Address

Mailing Address Same as Physical Address

Business Phone

Business Fax

Remittance / Payment Address

Preferred Contact Method

Email Phone Fax

Best Time To Contact

Morning (8AM-12PM) Afternoon (12PM-5PM) Anytime

How many practice identifiers?

Ownership, Control & Administrative Structure

Providers Requiring Enrollment

Common Medical Specialties

Family Medicine Internal Medicine Pediatrics Geriatrics Med-Peds Urgent Care Occupational Medicine Preventive Medicine OB/GYN Maternal-Fetal Medicine Cardiology Interventional Cardiology Dermatology ENT / Otolaryngology Gastroenterology General Surgery Orthopedic Surgery Sports Medicine Neurology Neurosurgery Pulmonology Sleep Medicine Endocrinology Nephrology Rheumatology Urology Ophthalmology Optometry Allergy / Immunology Infectious Disease Hematology / Oncology Radiation Oncology Pain Management Anesthesiology Physical Medicine & Rehabilitation Podiatry Wound Care Hospitalist / Nocturnist Emergency Medicine Critical Care Radiology Pathology Genetics Other

Advanced Practice & Other Provider Types

Nurse Practitioner - Family Nurse Practitioner - Adult / Geriatric Pediatric Nurse Practitioner Women’s Health NP Psychiatric NP Physician Assistant Certified Nurse Midwife Certified Registered Nurse Anesthetist Clinical Nurse Specialist Registered Dietitian / Nutritionist Diabetes Educator Genetic Counselor Audiologist Other

Age Groups / Patient Populations

Infants (0-2 years) Children (3-12 years) Adolescents (13-17 years) Adults (18-64 years) Older Adults / Geriatric Women’s Health Men’s Health Pregnancy / Maternity Medically Underserved / Low-Income Populations Medicare Beneficiaries Medicaid Populations Commercial / Employer Populations Complex / Chronic Conditions Surgical Patients Hospital Follow-up / Transitional Care Workers Compensation / Occupational Health All Ages Other

Additional Notes About Patient Population, Languages, Access Needs, or Community Focus

Core Medical / Office-Based Services

New Patient Visits Established Patient Visits Annual Wellness / Preventive Visits Sick Visits / Acute Care Chronic Condition Management Medication Management Pre-op Clearance Post-Hospital Follow-up Care Coordination & Referrals Vaccines / Immunizations Health Risk Assessments Disease-Specific Education Minor Procedures Basic Wound Care Injections / Infusions Point-of-Care Testing CLIA-Waived Testing Specimen Collection EKG / ECG Spirometry / Pulmonary Testing Remote Patient Monitoring Chronic Care Management Transitional Care Management Telehealth Visits Other

Service Delivery Type

In-Person Telehealth Only Hybrid Mobile / Home-Based Other

Facility / Location Type

Office Hospital ASC SNF / Nursing Facility Home Mobile Other

Community Size

Average Monthly Patient Volume

CPT / HCPCS Codes Commonly Used

Visit Types

In-Office Telehealth Home / Mobile Hospital Facility Procedures Diagnostics Other

Services Not Currently Billed but Planned

Specialty Service Categories

Primary Care / Preventive Medicine Pediatric Care / Well-Child Care OB/GYN / Prenatal / Gynecologic Care Cardiology Testing and Consults Dermatology Medical / Surgical Services ENT Procedures / Audiology Coordination GI Consults / Endoscopy Coordination General Surgery Consults / Procedures Orthopedic / Sports Medicine Services Neurology Consults / EEG Coordination Pulmonology / Sleep Services Endocrinology / Diabetes Care Nephrology / Dialysis Rounding Rheumatology / Infusion Coordination Urology Procedures Ophthalmology / Eye Care Allergy Testing / Immunotherapy Infectious Disease Consults Oncology / Hematology Consults Pain Management Procedures PM&R / Rehab Medicine Podiatry / Foot and Ankle Care Wound Care / Debridement Hospitalist / Inpatient Rounding Emergency / Urgent Care Services Radiology Interpretation Pathology Interpretation Other

Describe Specialty Services Offered

Hours of Operation

Enter the opening and closing time for each weekday.

DayOpening TimeClosing Time

Monday

Tuesday

Wednesday

Thursday

Friday

Weekend Hours Available?

Yes No

DayOpening TimeClosing Time

Saturday

Sunday

Telehealth Capabilities

Video Visits Store-and-Forward Emergency Triage Follow-ups

Referral Management Process

Quality / Compliance Programs

PCMH HEDIS Quality Reporting Value-Based Care MIPS/QPP Other

Prior Authorization / Referral Requirements

Languages Offered / Accessibility Needs

Primary Hospital Affiliation

Secondary Hospital(s) / Facilities

Admitting Privileges Needed?

Yes No Not Applicable

ASC / Procedure Center Affiliations

SNF / Nursing Facility / Home Care Affiliations

Imaging / Lab / Ancillary Partners

Community Partnerships

Schools Public Health Specialty Centers Social Services Employers Other

Billing Model / Special Billing Considerations

Group Billing Professional-only Billing Incident-to Billing Split/Shared Services Global Billing for Diagnostics Professional Component Only Technical Component Onsite Facility-Based Professional Billing Telehealth Modifiers CLIA Lab Billing Immunization / Vaccine Billing Care Management Billing Hospital Rounding / Consults Surgical Assistant Billing ASC / Procedure Coordination FQHC/RHC Billing Workers Compensation No-Fault / Auto Other

Place of Service Codes

Select all Place of Service codes that apply.

01 - Pharmacy 02 - Telehealth Provided Other than in Patient's Home 03 - School 04 - Homeless Shelter 05 - Indian Health Service Free-Standing Facility 06 - Indian Health Service Provider-Based Facility 07 - Tribal 638 Free-Standing Facility 08 - Tribal 638 Provider-Based Facility 09 - Prison / Correctional Facility 10 - Telehealth Provided in Patient's Home 11 - Office 12 - Home 13 - Assisted Living Facility 14 - Group Home 15 - Mobile Unit 16 - Temporary Lodging 17 - Walk-In Retail Health Clinic 18 - Place of Employment / Worksite 19 - Off Campus Outpatient Hospital 20 - Urgent Care Facility 21 - Inpatient Hospital 22 - On Campus Outpatient Hospital 23 - Emergency Room / Hospital 24 - Ambulatory Surgical Center 25 - Birthing Center 26 - Military Treatment Facility 27 - Outreach Site / Street 31 - Skilled Nursing Facility 32 - Nursing Facility 33 - Custodial Care Facility 34 - Hospice 41 - Ambulance / Land 42 - Ambulance / Air or Water 49 - Independent Clinic 50 - Federally Qualified Health Center 51 - Inpatient Psychiatric Facility 52 - Psychiatric Facility / Partial Hospitalization 53 - Community Mental Health Center 54 - Intermediate Care Facility / I/DD 55 - Residential Substance Abuse Treatment Facility 56 - Psychiatric Residential Treatment Center 57 - Non-Residential Substance Abuse Treatment Facility 58 - Non-Residential Opioid Treatment Facility 60 - Mass Immunization Center 61 - Comprehensive Inpatient Rehabilitation Facility 62 - Comprehensive Outpatient Rehabilitation Facility 65 - End-Stage Renal Disease Treatment Facility 66 - PACE Center 71 - Public Health Clinic 72 - Rural Health Clinic 81 - Independent Laboratory 99 - Other Place of Service

Specify Other Place of Service

Claim Form(s) Used

Taxonomy Code(s)

Common CPT / HCPCS / Revenue Codes

Modifiers Commonly Used

Referring / Ordering Provider Required on Claims?

Yes No Depends

Prior Authorization Required?

Yes No Service-dependent

Electronic Claims Clearinghouse

ERA / EFT Setup Needed?

Yes No

Bank Account / Voided Check Available?

Yes No

Existing Contracts or Network Participation

Payers to Enroll With

Medicaid States

MCO Name

Commercial Plan Type

Requested Credentialing / Enrollment Services

Initial Credentialing Recredentialing Medicare Enrollment Medicaid Enrollment Commercial Insurance Enrollment DMEPOS Enrollment ASC Enrollment Home Health Enrollment Hospice Enrollment Lab / CLIA Enrollment Imaging / IDTF Enrollment CAQH Setup / Maintenance NPI Registration Address Updates Ownership Change Revalidation EFT / ERA Setup Payer Contracting Other

Preferred Start Date

Target Go-Live / Effective Date

Urgency Level

Special Instructions / Notes

Organization-Level Documents

Provider-Level Documents

Client Name (Typed) *

Date *

Authorized Signature Name *

Title *

Electronic Signature *

Draw Signature Upload Signature

Uploading...

Signature Date *

I certify that all information provided in this application is true, complete, and accurate.

✓

Thank You!

Your application has been submitted for review.

We’ve received your Medical Providers Credentialing Client Discovery Form. Our team will review the information and contact you if anything else is needed.

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Healthcare Organizations

Medical Specialties

Credentialing Client Discovery Form

(Medical Providers Credentialing)

Ownership, Control & Administrative Structure

Providers Requiring Enrollment

Common Medical Specialties

Advanced Practice & Other Provider Types

Age Groups / Patient Populations

Core Medical / Office-Based Services

Specialty Service Categories

Organization-Level Documents

Provider-Level Documents

Thank You!

Maximize Your Revenue. With Expert RCM Services

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